Blue Star Insurance Agency
Auto Insurance Quote
Primary Policyholder's Name
First Name
Last Name
Gender
Male
Female
Marital Status
Single
Married
Widowed
Phone Number
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Driver's License Number
Do you own your home?
Yes
No
Would you like a homeowner's insurance quote for a possible discount?
Yes
No
How do you want to pay for your auto insurance policy?
One Month at a Time
3 Months at a Time
6 Months at a Time
1 Year at a Time (if available)
Do you want to have auto pay enabled?
Yes
No
Are you currently insured?
Yes
No
Current Auto Insurance Policy Expiration Date
-
Month
-
Day
Year
Date
Have you had any tickets in the past 3 years?
Yes
No
Please explain your tickets. Be detailed and include dates of the tickets.
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address different than your physical address?
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many additional driver's will be included on the auto policy?
1
2
3
4
Will you have any "excluded drivers" listed on the policy? An excluded driver is a person that lives in your household but does not drive your vehicles. If they were to get into an accident in one of your covered vehicles, your policy will not cover the accident.
Yes
No
Continue to Driver Information
Back
Next
Submit
Driver 2 Name
First Name
Last Name
Driver 2 Date of Birth
-
Month
-
Day
Year
Date
Driver 2 Driver's License Number
Driver 2 Gender
Male
Female
Driver 2 Marital Status
Single
Married
Widowed
Driver 3 Name
First Name
Last Name
Driver 3 Date of Birth
-
Month
-
Day
Year
Date
Driver 3 Driver's License Number
Driver 3 Gender
Male
Female
Driver 3 Marital Status
Single
Married
Widowed
Driver 4 Name
First Name
Last Name
Driver 4 Date of Birth
-
Month
-
Day
Year
Date
Driver 4 Driver's License Number
Driver 4 Gender
Male
Female
Driver 4 Marital Status
Single
Married
Widowed
Driver 5 Name
First Name
Last Name
Driver 5 Date of Birth
-
Month
-
Day
Year
Date
Driver 5 Driver's License Number
Driver 5 Gender
Male
Female
Driver 5 Marital Status
Single
Married
Widowed
Excluded Driver 1 Name
First Name
Last Name
Excluded Driver 1 Date of Birth
-
Month
-
Day
Year
Date
Excluded Driver 2 Name
First Name
Last Name
Excluded Driver 2 Date of Birth
-
Month
-
Day
Year
Date
Continue to Vehicle and Coverage Information
Back
Next
What type of coverage are you looking for?
Liability Only
Liability & Uninsured Motorists
Full Coverage
Requested Liability / Uninsured Motorist Coverage Amount
$25,000 / $50,000 / $10,000
$25,000 / $50,000 / $25,000
Other
Do you wish to include Medical coverage?
Yes
No
Do you wish to include Towing and Rental?
Yes
No
Requested Deductible Amount
$500.00
$1000.00
Other
How many vehicles are you needing to include on this auto policy?
1
2
3
4
Vehicle 1 VIN
Vehicle 1 Year
Vehicle 1 Make
Vehicle 1 Model
Will this vehicle have full coverage?
Yes
No
Vehicle 2 VIN
Vehicle 2 Year
Vehicle 2 Make
Vehicle 2 Model
Will this vehicle have full coverage?
Yes
No
Vehicle 3 VIN
Vehicle 3 Year
Vehicle 3 Make
Vehicle 3 Model
Will this vehicle have full coverage?
Yes
No
Vehicle 4 VIN
Vehicle 4 Year
Vehicle 4 Make
Vehicle 4 Model
Will this vehicle have full coverage?
Yes
No
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